Provider Demographics
NPI:1306984323
Name:WEAVER, ROGER LOUIS (PA-C)
Entity type:Individual
Prefix:MR
First Name:ROGER
Middle Name:LOUIS
Last Name:WEAVER
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
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Other - Credentials:
Mailing Address - Street 1:1009 3RD AVE
Mailing Address - Street 2:
Mailing Address - City:WEST POINT
Mailing Address - State:GA
Mailing Address - Zip Code:31833-1215
Mailing Address - Country:US
Mailing Address - Phone:706-645-1046
Mailing Address - Fax:877-898-1518
Practice Address - Street 1:8491 HOSPITAL DR
Practice Address - Street 2:176
Practice Address - City:DOUGLASVILLE
Practice Address - State:GA
Practice Address - Zip Code:30134-2412
Practice Address - Country:US
Practice Address - Phone:706-645-1046
Practice Address - Fax:877-898-1518
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-02
Last Update Date:2013-01-07
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
GA1530363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
GAR94773Medicare UPIN